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CORONERS ACT, 2003
SOUTH AUSTRALIA
FINDING OF INQUEST
An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 28th, 29th and 30th June 2006, and the 3rd January 2007, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Brodie Sian Foot.
The said Court finds that Brodie Sian Foot aged 23 years, late of Unit 6, 31 Parkmore Avenue, Sturt died at Somerton Park, South Australia on the 24th day of March 2004 as a result of drowning and citalopram overdose. The said Court finds that the circumstances of her death were as follows:
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1. Introduction
1.1. Brodie Sian Foot was a twenty-three year old woman who was found deceased in the sea near Somerton Park on 24 March 2004. She was single, and lived with her five year old son in rented accommodation. She was a second year at Flinders University, being enrolled in the Occupational Therapy course at that institution. She was in receipt of a supporting parents benefit. She had recently seen a doctor, and had been commenced on anti-depressant medication. A post mortem examination was conducted on 25 March 2004, and the cause of death was given as follows:
‘1A) Drowning.
1B) Citalopram overdose.’
(Exhibit C2a)
1.2. The focus of the Inquest was on the events of 17 March 2004. On that day, Ms Foot made a number of efforts to obtain medical assistance for herself. She presented to a general practitioner who referred her to the Flinders Medical Centre, which after some assessment discharged her, after which she finally visited a second general practitioner who worked at the same practice as the general practitioner she had seen earlier that day. She was very distressed, apparently as a result of a relationship break-up with her partner some time before, and, according to expert evidence provided to the Court, was suffering from a significant depressive condition and almost certainly that of a major depressive disorder.
1.3. The movements and activities of Ms Foot between 17 March 2004 and 24 March 2004 when she was found in the ocean off Somerton beach were not examined in detail at the Inquest. Inquiries were made Detective Senior Constable McLean in an effort to establish what, if any, other contacts Ms Foot may have had with the health system during that period. In particular, inquiries were made with the Health Insurance Commission (Commonwealth). That Commission provided Detective Senior Constable McLean with certain information which was not produced to the Inquest by reason of secrecy provisions contained in the Health Insurance Act 1973 (section 130(3A)) and the National Health Act 1953 (section 135A(3)). Those provisions prevented disclosure of the information beyond Detective Senior Constable McLean and persons involved in the investigation. However, had the material elicited from the Health Insurance Commission opened any lines of inquiries there is no doubt that Detective Senior Constable McLean would have pursued them.
2. Dr Chew – Ms Foot’s first medical appointment on 17 March 2004
2.1. Dr Angela Chew gave evidence at the Inquest. She also provided a very short written statement to Detective Senior Constable McLean by letter dated 8 April 2005 which was admitted as evidence as Exhibit C13 in these proceedings. Ms Foot attended at the Marion Domain Medical and Dental Centre where Dr Angela Chew practiced. DrChew had not seen Ms Foot before that day, and according to records of the Marion Domain Medical and Dental Centre which were put before the Court, she had only attended at the centre on one previous occasion on 6 January 2004 for an unrelated purpose.
2.2. Dr Chew made a brief computer record of the consultation as follows:
‘distressed crying – depression – several months – not on Rx (meaning no treatment)
worse last night – suicidal ideation
no family support
Rx – ref FMC
Outbox: Referral Letter’ (The words in parenthesis are mine).
(Exhibit C15)
2.3. Dr Chew did write a letter to the Flinders Medical Centre Emergency Department doctor, a copy of which was admitted as Exhibit C14. The letter is extremely brief and is as follows:
‘Thank you for your advice and help with the continuing management of this patient who presented today with depression & suicidal ideation & distressed.’
2.4. Dr Chew stated in evidence that her reason for the referral to Flinders Medical Centre was that Ms Foot was depressed and had suicidal thoughts and therefore she needed immediate treatment because she was at risk of harming herself. Dr Chew stated that she herself could not manage Ms Foot that morning and therefore referred her to Flinders Medical Centre (T26-27).
2.5. Dr Chew never saw Ms Foot again. She was shown a copy of a facsimile transmission from the Flinders Medical Centre Emergency Department addressed herself and apparently sent on 18 March 2004 at 0604. The facsimile records that MsFoot did indeed attend at the Flinders Medical Centre Emergency Department on Wednesday 17 March 2004 at 10:08 am. It recorded that her presenting condition was “suicidal ideation, depression, not coping”. It gave a diagnosis of “major depressive disorder, single episode”. It then stated “Not Admitted to FMC – Discharged to home”. Dr Chew acknowledged that the facsimile was received by her practice. It was admitted as Exhibit C16 in these proceedings. It appears that DrChew was consulting with Ms Foot at approximately 9:49 am that morning (T23) therefore Ms Foot wasted no time in proceeding to the Flinders Medical Centre with the referral letter from Dr Chew.
3. Ms Foot attends Flinders Medical Centre
3.1. Dr Ching
Dr Peter Chi-Ming Ching gave evidence at the Inquest. He also provided at statement to Detective Senior Constable McLean which was admitted and marked Exhibit C17. He is now an anaesthetic registrar at the Women’s and Children’s Hospital. In March 2004 he was a second year registered medical officer in the Emergency Department at Flinders Medical Centre. On 17 March 2004 he was working on the day shift. He did not recall Ms Foot and had to resort to the Flinders Medical Centre notes. Those notes showed that Ms Foot was seen by a triage nurse who made some initial observations of temperature, pulse, breathing and blood pressure at 11:15 am. DrChing stated he would have seen Ms Foot after that initial assessment. He took a history which identified Ms Foot’s age and living arrangements and recorded that she presented with suicidal ideation and depression. She had no significant past medical history and was not taking medication. She told him that she had a long history of depression which had never been treated, but which had become acutely worse in the last few days. She referred to relationship problems with her partner or friends but would not reveal more about that to him. She stated that she was constantly crying and had increased alcohol use. She stated that she had occasional suicidal thoughts. She told him that she had plans but she would not reveal them. She told him that she did not have any close family or friends for support, had not obtained any psychiatric services in the past, and that her general heath was good.
3.2. Dr Ching did a screening physical examination and did not find any significant.
3.3. Dr Ching stated that the fact that Ms Foot had told him that she had suicidal plans but that she would not reveal to him what her plans were “is a sign of high risk” (T44). He decided to refer her for further psychiatric assessment in the Emergency Department. He stated that during the day shift there is always a mental health nurse who is attached to the Emergency Department and the Emergency Department registered medical officer (RMO) usually refers psychiatric patients for assessment by the mental health nurse. The mental health nurse then communicates with the psychiatric registrar or consultant.
3.4. He stated that he would have done a direct verbal handover of Ms Foot to the mental health nurse who was on duty. He stated that he would have also handed over the Emergency Department progress notes and the general practitioner referral letter. He stated that he had expected that Ms Foot would have been seen by a psychiatric registrar at some point because on his assessment she had “high risk suicidal signs” (T46). He did stated that not all patients are necessarily seen by the psychiatric registrar. He stated that if a patient had presented on multiple occasions with non life threatening complaints and simply needed reassurance, the patient might be seen by a mental heath nurse but not a psychiatric registrar. However, he stated that “my expectation would be that the psychiatric registrar would see all patients who presented for the first time” (T48). He stated that his expectation was that Ms Foot would be seen by a psychiatric registrar.
3.5. Dr Ching stated that he would have considered other possible explanations of a non-psychiatric nature for Ms Foot’s presenting condition. He stated that he would have ruled out hyperthyroidism, for example, on her physical examination as her presenting condition did not indicate it.
3.6. Dr Ching stated that when he made his handover to the mental health nurse, the nurse in question was Michael Hawkins. Dr Ching stated the would have brought his documentation to Mr Hawkins and told Mr Hawkins about Ms Foot’s depressive condition, her suicidal ideation, and “I would have emphasised the point that she would have had plans but didn’t reveal them” (T57). He stated that he would have done that because it was something which he considered to be quite significant.
3.7. Dr Ching stated that he was not the author of the facsimile advise of discharge (Exhibit C16).
3.8. Dr Ching stated that he did not have any expectations as to whether Ms Foot would be admitted or not because it was up to the psychiatric services within Flinders Medical Centre to determine whether the patient needs to be admitted or can be managed as an outpatient or in the community (T58).
3.9. Mental Health Nurse Michael Hawkins
Mr Michael Hawkins, Registered General Nurse and Mental Health Nurse gave evidence at the Inquest. He holds a Batchelor of Nursing and a Graduate Diploma of Mental Health Nursing both awarded by Flinders University. He provided a statement to Detective Senior Constable McLean which was admitted as Exhibit C19 in these proceedings.
3.10. Mr Hawkins stated that he works with the Southern Assessment and Crisis Intervention Service (Southern ACIS) and from time to time relieves in the Emergency Department at Flinders Medical Centre as the ACIS nurse.
3.11. He provided an account of the role of the ACIS nurse at the Emergency Department at Flinders Medical Centre which corresponded largely with that of Dr Ching. He stated that the patient would be seen by the triage nurse, and if assessed as being a psychiatric patient, would then be seen by the registered medical officer on duty. If the registered medical officer confirmed the view that there was a psychiatric issue, then the registered medical officer would refer the patient to the mental health team. At that point the Mental Health Nurse would become involved. He stated that the Mental Health Nurse might send the patient to the psychiatric registrar or consultant, but added that it was his understanding of the practice at the time, which I took to be March 2004, that the Mental Health Nurse might also decide upon a management plan for a patient. He said that in that case the plan would be discussed with the registrar or consultant and if agreed the Mental Health Nurse would implement the plan. The implication of this was that he had an understanding that not all patients would necessarily be referred to the psychiatric registrar or consultant by the Mental Health Nurse. The relevance of this will become more apparent in due course.
3.12. Mr Hawkins stated that he could not recall now but that it was most likely that he would have had the documentary material which had been gathered to that point in relation to Ms Foot, namely the progress notes of Dr Ching, and Dr Chew’s note of referral. Mr Hawkins recorded his own history and assessment on a document headed “Community Assessment Record”. He stated that the assessment would have taken approximately forty-five minutes. He assessed Ms Foot as a young person of high alibility to carry out daily living. He noted that she was enrolled in Occupational Therapy and had completed her first year and was therefore a highly functioning person who was able to overcome disadvantages in her life. He did not think she was chronically depressed but was depressed by her recent break-up. He rated her risk of self-harm to be moderate. He noted that she had a good relationship with her family and particularly her younger brother. He did not think her stated plan of overdosing on “whatever I can get” was a specific plan against the context of her relationship break-up.
3.13. He assessed that she had situational crisis leading to a depressive episode. He recorded that he had discussed the matter with the psychiatric registrar who, on MrHawkins recommendation, provided four Diazepam 5 mg tablets to help with sleep over the next two or three days. He stated that this would have been approved by the psychiatric registrar but he could not remember who the registrar was. He acknowledged a photograph of an envelope bearing the words “Diazepam 5 mg” as a depiction of the envelope he would of provided to Ms Foot containing the four Diazepam tablets and that the handwriting was his.